A nurse is admitting a client to the birthing unit who started having contractions an hour ago. The nurse determines the client is 80% effaced and 8 cm dilated.
What condition is the client at risk for?
Incompetent cervix
Hyperemesis gravidarum
Postpartum hemorrhage
Ectopic pregnancy
The Correct Answer is C
Choice A rationale
An incompetent cervix is a condition that occurs when weak cervical tissue causes or contributes to premature birth or the loss of an otherwise healthy pregnancy. This condition is not directly related to the client’s current state of being 80% effaced and 8 cm dilated.
Choice B rationale
Hyperemesis gravidarum is a condition characterized by severe nausea, vomiting, weight loss, and electrolyte disturbance. Mild cases are treated with dietary changes, rest, and antacids.
More severe cases often require a stay in the hospital so that the mother can receive fluid and nutrition through an intravenous line. This condition is not directly related to the client’s current state of being 80% effaced and 8 cm dilated.
Choice C rationale
Postpartum hemorrhage is a condition that can occur due to a variety of factors, one of which is a rapid or prolonged labor, which can result in uterine atony. Given that the client is 80% effaced and 8 cm dilated, she is in active labor and could potentially be at risk for postpartum hemorrhage.
Choice D rationale
An ectopic pregnancy is a pregnancy in which the fertilized egg implants outside the uterus. The client is already in active labor, which means the pregnancy is not ectopic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Fresh citrus fruits are a good source of vitamin C, but they do not contain vitamin B125. Vitamin B12 is not naturally present in plant foods, so vegans need to get it from fortified foods or supplements.
Choice B rationale
Raw carrots are a good source of vitamins A and K, and dietary fiber, but they do not contain vitamin B125. Vegans need to get vitamin B12 from other sources.
Choice C rationale
Brown rice is a good source of B vitamins like B1 (thiamin) and B3 (niacin), but it does not contain vitamin B125. Vegans need to get vitamin B12 from other sources.
Choice D rationale
Fortified soy milk is a good source of vitamin B12 for vegans. Many brands of soy milk are fortified with vitamins, including B12, making them a good choice for vegans looking to increase their vitamin B12 intake.
Correct Answer is C
Explanation
Choice A rationale
Applying a moist, warm compress to the perineum is not the recommended care for a client with a fourth-degree laceration of the perineum 12 hr postpartum.
Choice B rationale
Administering methylergonovine 0.2 mg IM is not the recommended care for a client with a fourth-degree laceration of the perineum 12 hr postpartum. Methylergonovine is a medication used to prevent or control bleeding of the uterus following childbirth or abortion.
Choice C rationale
Providing the client with a cool sitz bath is the correct action. A sitz bath can help to soothe the perineal area, reduce inflammation, and promote healing.
Choice D rationale
Applying povidone-iodine to the client’s perineum after she voids is not the recommended care for a client with a fourth-degree laceration of the perineum 12 hr postpartum. Povidone-iodine is an antiseptic used for skin disinfection before and after surgery.
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